SELF EVALUATION
POLYSOMNOGRAPHY SKILLS PROFICIENCY CHECKLIST

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DIRECTIONS: Place an x in the box that best describes your level of proficiency for each of the skills presented.

LEVELS OF PROFICIENCY KEY:

HP = Highly Proficient; Extensively experienced; able to supervise and/or train others.

VE = Very Experienced; can perform well, without assistance or supervision.

EX = Experienced; competent; can perform independently; may need initial review or supervision.

SE = Some Experience; need review and assistance or supervision.

NE = No Experience.
PROFICIENCY LEVEL PROFICIENCY LEVEL
PATIENT PREPARATION: HP VE EX SE NE DAYTIME STUDIES: HP VE EX SE NE
Standard 10-20 Hook-up Wake Study
Full Head Hook-up Multiple Sleep Latency Test (MSLT)
Seizure Hook-up
Patient Pre-study Calibration SPECIAL STUDIES AND PROCEDURES:
Patient CPAP/IPAP Trials Seizure Study
Esophageal Pressure Tube Insertion
ROUTINE SLEEP STUDIES: Night Terror Study
Baseline Polysomnogram Study of Sleep Walking
     without CPAP/IPAP Nocturnal Penile Tumescence (NPT)
Split-night Polysomnogram Hypnogogic Hallucinations
     with CPAP/IPAP Headache (Migraine, Cluster, etc.)
Full Night Polysomnogram Research Studies
     with CPAP/IPAP Titration (alcohol, drugs, safety, driving, etc.)
Newborn Polysomnogram Insomnia
     with or without CPAP/IPAP Data Scoring
Infant Polysomnogram SYSTEMS EXPERIENCE:
     with or without CPAP/IPAP 100% Digital
Restless Legs Syndrome Paper (graph)
Periodic Leg Movement Combined Paper and Digital
SAO2 and CO2 Monitors Windows-based Software
Breathing Abnormalities DOS-based Software
EQUIPMENT USAGE: HP VE EX SE NE    REGISTRY/LICENSURE:
Grass    RPSGT (Registered Polysomnographer)
Sandman    EEG (Electro-Encephalographic Technician)
Sensormedics    CRTT (Certified Respiratory Therapist Technician)
Alice 3    RRT (Registered Respiratory Therapist)
NCI    Other:
Nihon Koden Analog
Teca    QUALIFICATIONS:
Nicolet    BCLS/CPR
Biologic    ACLS
Digitrace    Other:
Other, please list:    Other:
   Other: 
© Rapid Temps, Inc., rev 12-99
Date:

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